Late miscarriage: second trimester loss

Late miscarriage: second trimester loss

Miscarriage is sadly common. Around one in five pregnancies ends this way and it can be a very unhappy experience. Most miscarriages happen in the first 12 or 13 weeks of pregnancy. It is much less usual to miscarry after 13 weeks and if this has happened to you, you may have been very shocked. We do hope that this leaflet helps a little at what might be a very difficult time. What do you mean by late miscarriage? Late miscarriage is where the baby dies between 14 and 24 weeks of pregnancy. It is also called second-trimester or mid-trimester miscarriage as it happens in the middle stage of pregnancy. Doctors divide pregnancy into three stages: the first trimester is up to 13 weeks; the second, or middle, trimester is from 14 to 24 weeks; the third trimester is from the start of the 25th week of pregnancy onwards. The leaflet doesn t include missed or silent miscarriages, where the baby dies before 14 weeks, even if the actual miscarriage happens later. We talk about these in our other leaflets, especially Your miscarriage and Why me? It also doesn t cover losses which happen at 24 weeks or later these are called stillbirths. You may find it hard to understand why a very late loss is called a miscarriage and not a stillbirth particularly as it means that there is no birth or death certificate. This is because 24 weeks of pregnancy is the legal age of viability the stage at which a baby is thought to stand a good chance of surviving if born alive. For some people, hearing the late loss of their baby called a miscarriage can make them even more distressed. She was a perfect, tiny little baby but officially she never existed. She didn t even have a birth or death certificate. How can someone decide she was never a person? 2

The physical process Your miscarriage may have happened naturally, or you may have had to have your labour induced (started off). Natural miscarriage If you miscarried naturally, you may have had period or labour pains strong contractions in your abdomen or pain in your back.you might have been aware of your waters breaking, or they might have stayed intact until your baby was born. It might all have happened quite quickly and once it started, there wouldn t be any way of stopping it.you might have delivered your baby at home or in the hospital or perhaps somewhere else. My baby was born following several hours of very painful contractions. The release of pain when my waters broke came as a relief, but also a nightmare at the same time. When they told me they couldn t find a heartbeat, I think my heart stopped too. I was full of the joys of being pregnant, only to feel I had been hit by a train head on. Silent miscarriage You may have had no sign that anything was wrong with your pregnancy, but an ultrasound scan showed your baby had died. You will probably have had your labour induced that is, started artificially to deliver your baby. Hospital staff might have offered choices about how to manage the labour and they should have told you what was likely to happen. You might have wanted to start the process of labour as soon as possible, or you may have preferred to go home and think about it for a few days. Either way, these may have been very difficult and upsetting decisions to have to make. 3

Seeing and holding your baby With a late miscarriage, you are likely to be able to see your baby and perhaps to hold him 1. You might be very worried about what your baby will look like and choose not to look. Hospital staff may offer to take a photo of him and save it for you in case you want to look later. It may be that someone else will describe your baby to you and that will help you decide. There is no right or wrong thing to do it depends how you and your partner feel. I initially declined to hold my baby. I was so scared about how he might look. But a few hours later I changed my mind and a very kind midwife brought him back into the room. I was pleased I d seen my baby, who was tiny but perfectly formed. 4 1 The midwife might not be able to tell you what sex the baby is at birth as it can be difficult to be certain with a tiny baby.to make this leaflet easier to read, we have chosen to use the words he, him and his.

What causes a late miscarriage? Over the next two pages, we ll list the main causes of late miscarriage. Some can cause earlier losses too. Others may cause a problem after 24 weeks of pregnancy as well as before. Most miscarriages, at whatever stage, happen because of an abnormality in the baby. Chromosome problems Examples of chromosome problems are Downs Syndrome, Edwards Syndrome and Turners Syndrome. These are usually one-off abnormalities, happening out of the blue. But they might be due to a problem that you and/or your partner have, probably without knowing. With a late miscarriage, it is possible to examine the baby s chromosomes from samples taken from the placenta and umbilical cord, as long as you agree. Genetic problems Our chromosomes carry our genes. We all have many thousands of genes; we also all have some abnormal genes. Sometimes these genes can cause the baby to die in pregnancy. Genetic problems are more likely to cause early miscarriage. But if your doctor suspects that a genetic problem caused your miscarriage, s/he might refer you to a specialist to have tests and perhaps advice about future pregnancies. Structural problems This means problems in the baby s body, for example spina bifida or a congenital heart defect.these are sometimes seen on an ultrasound scan, but sometimes they are only discovered after the baby is born. If your baby is found to have this kind of problem, you should be offered genetic counselling so that you can find out more about the chances of it happening again. Your and your partner s chromosomes can be examined from a blood test. This information will help the genetic counsellor to tell you what the risk is of a similar problem happening again. If your doctor thinks that you have a higher risk than most people of having a baby with a chromosome abnormality, you may be offered extra tests in your next pregnancy. 5

Other causes of late miscarriage Anatomical problems If you have an unusually shaped womb (uterus), especially one that is partly divided in two (an arcuate uterus), this might have caused your miscarriage. Your doctor might suggest an operation to correct the shape of your womb. If you have a weak cervix (sometimes called an incompetent cervix ), this might have caused your miscarriage. The cervix (the neck of the womb) should stay tightly closed during pregnancy. But if it is weak for some reason, it may open as the baby grows bigger, and it won t be able to hold the baby inside. If your doctor thinks this caused your miscarriage, s/he may suggest that you have a strengthening stitch, called a cervical stitch, in your next pregnancy. This is usually done under a general anaesthetic at 13 or 14 weeks of pregnancy. If your doctor is not sure whether this is the cause, then s/he may decide to monitor you closely in your next pregnancy, with regular scans to check your cervix. There is more detail in our leaflet The cervical stitch. Infection Some infections can cause a late miscarriage, either by infecting the baby or by infecting the amniotic fluid (the liquid around the baby). Infections directly affecting the baby include parvovirus, cytomegalovirus (CMV), and toxoplasmosis.these infections can cause the baby to die in the womb. They are unusual and do not usually happen in another pregnancy. Infections of the amniotic fluid can happen when bacteria (germs) that normally live in the vagina get into the womb. One example is bacterial vaginosis (BV), a common infection which has been associated with premature (early) labour. Antiphospholipid Syndrome (APS) APS is a condition that increases blood-clotting. It is sometimes called sticky blood syndrome or Hughes syndrome. If blood clots too easily during pregnancy, it can cause early or late miscarriage, as well as other pregnancy problems. If you haven t been tested for APS, you might want to ask your doctor to arrange this test.you will have two blood tests, taken at least twelve weeks apart, and if both are positive, you will be diagnosed as having APS. If you have APS, you will be treated with low-dose aspirin and possibly another blood-thinning drug called heparin in your next pregnancy. There is more detail in our leaflet Antiphospholipid Syndrome (APS) and pregnancy loss. 6

Can I find out why my baby died? After a late miscarriage most hospitals offer some investigations.they may involve tests of the baby and possibly blood tests for you and perhaps your partner. Investigation of your baby is called a post mortem (which means after death ). A post mortem is also called an autopsy. A post mortem examination can provide valuable information about your baby, your pregnancy, and your own health. It can also provide information which will help your doctor to care for you in a future pregnancy. A post mortem also confirms your baby s sex.that might be different from what was thought when the baby was born. How can I decide? To help you decide, you should have the chance to talk about it with someone who understands the process.we also describe what happens during the examination. We have written this in a separate section (on page 8) in case you d rather not read it. You don t have to feel rushed into making a decision.you may need time as well as clear information to help you decide, and a few days delay won t make a difference to the findings. If you decide not to have a post mortem examination, you can still ask for the placenta to be examined and for an external examination of your baby.this can provide information which may be helpful if you re thinking about trying again. A post mortem does not always provide a reason for a miscarriage. For some parents this is sad and frustrating. But if you are thinking about trying again, it can also be helpful to know that your baby was normal and there was no obvious reason for the miscarriage. We finally agreed on an external examination and a look at the chromosomes. The results were normal, which we found reassuring, even though we still had no explanation as to why we lost our baby. 7

What happens in the post mortem examination? If you agree to your baby having a post mortem examination, it will be carried out by a pathologist, a doctor who specialises in the study of disease and causes of death.the pathologist may specialise in diseases in pregnancy, babies and children. Your baby may have to be transferred to another hospital for the examination, but you should be told about this and when he will be returned.this might take up to eight weeks. A post mortem involves examining the baby carefully, outside and inside his body. Small samples of tissue are taken from each organ and are looked at under a microscope.this will show the pathologist if the tissues were developing normally or not. Sometimes special investigations are also needed, such as photographs, x-rays, bacteriology and virology to look for infections, and karyotyping to study the baby s chromosomes.this can usually be done on a small piece of skin. Sometimes it is only possible to examine an organ after what s called fixation.this means putting the organ in a chemical called formalin for a few days, to help firm the tissues.you will be asked about whether you want this to be done. You may also need to think about what you want to happen to the organs and tissues after examination. It is important to talk this over and ask any questions you may have.the organs can be returned to your baby s body after examination, but this may delay the funeral, if you are having one. The post-mortem examination takes up to several hours to perform. Afterwards, the incisions made to examine your baby internally will be repaired where possible and, if you wish, he can be wrapped or dressed to hide any marks.you can see your baby again afterwards if you want to. You can talk this through with the pathologist or other staff. The tissue removed at the post mortem will be examined in a laboratory.this can take some time and it may be several weeks before you can be given results. Your consultant will probably invite you to a follow-up appointment to discuss the results, or the results may be sent to your GP, who will talk about them with you. (See also Follow up, page 13) 8

What happens to my baby afterwards? When a baby is miscarried before 24 weeks of pregnancy, you don t have to have a burial or cremation for him or her. But your hospital may offer to arrange one or you may decide to arrange this yourself. Some hospitals offer burial or cremation for all babies that miscarry, whether early or late in pregnancy. Others have different arrangements for early and late losses. Some hospitals offer collective burial or cremation where a number of babies are buried or cremated together. The hospital staff should take time to explain to you what the hospital offers and should also give you written information. They should give you time to think about what you want to do.you may feel too shocked to be able to make a decision right away.this is a decision you probably never imagined that you would have to make. I was amazed by how helpful and sensitive the funeral directors were in organising my baby s burial. You can make your own arrangements for a funeral and/or burial or cremation if you prefer.you could talk to a funeral director or a minister of your own faith if you have one. The hospital chaplain may also be a good source of information, advice and support, even if you don t have any religious beliefs. You might decide that you want to bury your baby yourself.there are guidelines about how and where this can be done and you can get more information from us or from SANDS (see page 15). You may need to make your wishes very clear to hospital staff or your GP as they may not realise that this is allowed. You may want to ask staff to keep your baby until you are ready to decide. They should also understand if you feel you cannot make a decision at all. I had to make decisions beyond my wildest dreams. Did I want to cremate or bury the babies? I was making funeral arrangements when all I wanted to do was hold them in my arms and take them home forever. 9

Marking your loss Whether or not you have a funeral for your baby, you may feel you want to find other ways to mark his or her brief life. It may be important to you to name your baby. If you do not know whether your baby was a boy or a girl, you could choose a name that could be given to either. Some parents gather mementos in an album or a special box: for example, a scan photo, a hospital bracelet, letters or cards, and maybe a toy or clothes that they had ready for their baby. Some hospitals offer to make hand or footprints of babies miscarried late in pregnancy and may put them in a special memorial card. Other parents mark their loss in other ways, perhaps planting a bush or tree, making a donation to charity, or creating something else in their baby s memory. Your hospital may have a book of remembrance where you can enter your baby s name and the date of your miscarriage. Some hospitals hold regular remembrance services for babies who died during pregnancy or around birth. Can I have a certificate for my baby? The Registrar does not provide death certificates for babies miscarried before 24 weeks of pregnancy, but it may be possible to have a certificate from the hospital.this would note your baby s name, if you have given one, the date of the miscarriage and maybe some other details. If your hospital does not provide certificates, you could ask whether they would sign one which you provide.the Miscarriage Association and SANDS both provide outlines that you can use. A couple of weeks after I miscarried we bought two plants and planted them in the garden with a pebble pond and a pear tree in memory of our little one. 10

How will I feel after the miscarriage? Your body After your miscarriage, you are likely to have some bleeding and perhaps pain like a period.this might go on for several weeks. It is worth contacting your doctor: if the bleeding or pain increases if you have a vaginal discharge that looks or smells bad, or if you are worried about any other physical symptoms. Your doctor can also give you a medical certificate if you need one for work. And your midwife might offer to visit you at home to see how you are doing. Your breasts may produce milk and you might find this very upsetting. A well-supporting bra can help you feel more comfortable. If your breasts are painful, you might want to take a mild pain-killer such as paracetamol. If you have a lot of pain and discomfort, talk to your midwife, GP or the hospital staff.they may be able to give you tablets to reduce the production of milk.you can also buy breast pads at the chemist or supermarket to soak up any leaking milk. You may feel very tired for quite a long time after your miscarriage.your body needs time to recover from labour and maybe also from infection or treatment. If you are producing milk, that can be tiring too. Despite being tired, you may find it hard to sleep. Emotional distress can be exhausting too, and can affect how you feel physically. Your body may get back to normal quite quickly, or it may take longer, especially with a later loss. People have very different feelings about how they look.you might be upset if you still look pregnant and feel better when you can wear your ordinary clothes again. Or you may feel that getting back to your nonpregnant shape is somehow forgetting or betraying your baby.you might not want to let go of the look and feel of pregnancy. Try to give yourself time to recover. Sometimes the demands of home and work make that difficult.you might feel that the sooner you get back to your usual routine, the quicker you ll feel better.that might work, but don t be too surprised if it doesn t.you may just need more time. It may help to talk to someone who understands. See page 15 for some suggestions. I felt tired all the time and didn t want to get out of bed. I had a constant pain in my chest and a heavy feeling all over. 11

For those of us who have undergone the trauma and complex feelings following miscarriage, a little of that pain remains in a corner of ones heart forever. Barbara Dickson, singer and actress Your feelings There is no right way to feel after your miscarriage. And however you feel, you may show those feelings clearly or you might keep them hidden as much as you can. For example, you might feel very sad and cry, maybe a lot of the time. But perhaps it doesn t feel natural to cry, or you worry about upsetting other people. Or maybe you worry that if you start crying, you won t be able to stop. Coming home from hospital without your baby can be hard. If you have bought baby clothes and equipment, or decorated a room, it can be upsetting to see them, though you may find it comforting too. Here are some of the other ways that women and their partners say they feel: angry sometimes at particular people and sometimes just at the unfairness of it all jealous especially of pregnant women or couples with small babies guilty wondering if the miscarriage was somehow your fault lonely especially if people around you don t seem to understand You may find it hard to talk about what happened or how you feel. Or you might need to talk, to go over what happened again and again. It can sometimes be hard to find people who are willing to listen. Sometimes family and friends say the wrong thing, try to cheer you up, or just avoid talking about what has happened altogether. You may find you continue to grieve for your baby for much longer than you, or other people, expect.you might feel you ll never recover. For many people, it is not so much a matter of getting over their loss as learning to live with it.this can take time. My husband put all the baby things away out of sight, before I came home. He thought they d upset me. I got the littlest baby-gro out and just held it and I cried and cried. It was sort of comforting, in a way. 12

Your partner Your partner is also likely to be grieving for the loss of your baby but you may be coping with your feelings in different ways. Sometimes partners feel they have to be strong and supportive and so they keep their feelings hidden.the downside is that they may not get the support they need. It may be important to be open with each other. Your miscarriage might have brought you closer, but it might have put a strain on your relationship and that can be very hard to cope with. If the strain of your loss is pulling you and your partner apart, you may need to look for outside support (see page 15). You might not have a partner and be dealing with this alone. There is more detail in our leaflets Your feelings after miscarriage and Men and miscarriage. Will I have any follow-up? You should be offered a follow-up appointment with your hospital consultant a few weeks after your miscarriage. This is the opportunity to get the results of any investigations, ask any questions you have and find out about any treatment that might help now or in another pregnancy. You may not get answers to all your questions and that might be because there just isn t an answer. But it could be that the appointment is rushed or the doctor is not well prepared. It may help to talk to your GP, who might be able to find out more for you. GPs aren t always sent this information from the hospital, so allow time for him/her to chase it up if necessary. Whoever you see, it can be useful to take a written list of questions with you, as it s easy to forget once you are there.you might want to make notes of the information you are given, as there may be too much to take in and remember at the time. After a month had passed it became more and more difficult to say the right thing. We would talk to try and resolve things, but to no avail. I began throwing myself into work, creating extra work just to pass hours. 13

What about trying again? Deciding whether or not to try again can be difficult and you may have very mixed feelings about another pregnancy. You may want to try again as soon as possible, and feel that being pregnant will help you recover from this loss. But you might also be frightened that it could happen again. It might be something you don t want to think about at all, at least not now. If you do decide to try again, you may want to talk to your GP or hospital doctor about having extra check-ups or scans next time. You might find it helpful to read our leaflet Thinking about another pregnancy. Late miscarriage: a summary Miscarriage late in pregnancy is uncommon.you might have been very shocked when it happened. Going through labour and delivery can be very upsetting; and you may not be sure if you want to see your baby. You might be asked to make very difficult decisions about a post mortem and/or about burial or cremation. It might take time for you to decide whether or when to try again You may be very upset that a late loss is called a miscarriage rather than a stillbirth. It can help if you have people around you who can understand; and there are other places too where you can find help and support. All I wanted to do was get pregnant again, but it took several months to happen and that was an emotional struggle, particularly as my due date came and went. Finally I was pregnant and now have a beautiful little boy, but I still think about the baby I lost most days and he lives on in our hearts. 14

Where to go for help and support It can make a real difference to be able to talk to people who understand.you may be offered support or counseling through the hospital or your GP, or you might try one or more of the following organisations: The Miscarriage Association has a telephone helpline, a volunteer support service, an online support forum and a range of helpful leaflets. Tel: 01924 200799 www.miscarriageassociation.org.uk 17 Wentworth Terrace,Wakefield WF1 3QW SANDS (the Stillbirth and Neonatal Death Charity) offers support and information through local support groups, publications and a helpline Tel: 020 7436 5881 www.uk-sands.org 28 Portland Place, London W1N 4DE The British Association for Counselling and Psychotherapy can help you find a counsellor or psychotherapist. Tel: 0870 443 5252 www.counselling.co.uk Relate, Premier House, Carolina Court, Lakeside, Doncaster, DN4 5RA Relate can help with relationship problems. Tel: 0300 100 1234 www.relate.org.uk Herbert Gray College, Little Church Street, Rugby, CV21 3AP The Samaritans can help people in serious emotional distress, 24 hours a day. Tel: 08457 909090 www.samaritans.org.uk Thanks Our sincere thanks to Miss Judith Moore, Consultant Obstetrician, Nottingham University Hospitals (City Campus), for her help in writing this leaflet; and to everyone who shared their thoughts and experiences with us. Need to talk to someone who understands? Call our support line on 01924 200799. Monday to Friday, 9am-4pm Or email info@miscarriageassociation.org.uk 15

The Miscarriage Association 17 Wentworth Terrace Wakefield WF1 3QW Telephone: 01924 200799 e-mail: info@miscarriageassociation.org.uk www.miscarriageassociation.org.uk The Miscarriage Association 2011 Registered Charity Number 1076829 (England & Wales) SC039790 (Scotland) A company limited by guarantee, number 3779123 Registered in England and Wales Late/01/11